I am such a fan of Dr. Stahl's texts on Essential Psychopharmacology and his Prescriber's Guide, now both in their fourth editions, that I could hardly wait to see how he would handle the far more complex topic of violence. Central to Dr. Stahl's approach in his earlier texts has been the use of illustrations, diagrams, and tables to summarize vast swaths of clinical and scientific data, further explained in captions and supplemented by an extensive list of suggestions for further reading and access to online testing that allows one to earn continuing medical education (CME) credits upon completion. His earlier texts helped create a context in which more focused scientific papers can be better understood and critiqued, but those were limited to psychopharmacology in general, a subject well suited to the author's approach. Stahl's Illustrated Violence: Neural Circuits, Genetics and Treatment (hereinafter, Violence) is set up in the same way as the earlier books, and CME credits are earned by completing an online quiz. A very slim volume of only 103 pages including the index and front and back matter, the book is expensive, with a listed price of almost $50. Is it worth it? I had my concerns from the start, but a reference that elegantly summarizes the wide-ranging literature on the psychopharmacology of violence could be very useful. What I discovered surprised me.
The first sign of trouble had to do with the authors' definition of violence as “hostile, injurious or destructive behavior that may have various targets (self or other directed) and different modes of action (physical or verbal, direct or indirect)” (p 2). For those of us familiar with the daily challenges of working with violent patients in correctional, forensic, and mental health settings, broadening of the definition of violence to include indirect verbal expressions of hostility arguably stretches the concept to such an extent as to render it meaningless. Verbal aggression is certainly an important mechanism in psychological abuse of children and others, but whether it deserves to be classified as violence in the same category as a punch, stabbing, shooting, or rape is another matter. Psychopharmacological intervention is far more likely when the violence goes beyond words. There is no room in this spare book to explore the nosology of violence and the spectrum of violent behavior arising in association with, or in the absence of, distinct psychiatric disorders. The omission is disappointing.
The second sign of trouble is the authors' egregiously disproportionate emphasis on the association between violence and schizophrenia and psychotic disorders: 6 of the 10 multiple-choice practice questions address violence and schizophrenia directly; about one-third of the entries in the index refer directly to schizophrenia, psychosis, and antipsychotic drugs; and, when the entries referencing basic scientific data related to genetics, hormones, transmitter systems, and neural mechanisms are included, an even larger number of the indexed pages pertain to schizophrenia. Thus, between one-half and two-thirds of the entries in the index relate to schizophrenia and psychosis as the cause of violence. Of the 29 pages in the chapter on treatment, 23 concern the use of antipsychotic medications and the treatment of psychosis and schizophrenia. The sole page addressing mood stabilizers fails to do justice to the literature on the use of these medications in violent patients. Dr. Stahl's focus on violence in schizophrenia and psychosis at the expense of other categorical diagnoses does not reflect the literature. Going through Violence, I searched for data concerning posttraumatic stress disorder and violence, mood disorder and violence, attachment disorders and violence, alcohol or substance abuse and violence, a history of physical or sexual abuse as a child and violence, and personality disorders and violence, but found next to nothing. A multidimensional approach may have mitigated the severity of the imbalance and would have identified approaches to violence in individuals who have personality and character pathologies, with histories of poverty, neglect, and abuse during development. The book is advertised as a neuropsychiatric approach to violence, but the authors ignore the emerging consensus in cognitive neuroscience regarding the impact of adverse social and interpersonal conditions during development on brain maturation, function, and behavior in adults who engage in violent behavior.
Finally, the cartoonish approach to nonpharmacological treatment of aggression, displayed on one page showing a patient on a couch and a circle of empty chairs beneath reflects a further bias in the content and ignores the growing evidence of the effectiveness of cognitive and dialectical behavior therapies, as well as other non–medication-based approaches to mitigating the risk of violence across the board.
Stahl's psychopharmacology texts are excellent guides for those of us studying for maintenance-of-certification examinations. This book gives no such help.
The discourse on violence in forensic psychiatry is informed by a range of disciplines from neuroscience to sociology and criminology. This interdisciplinary aspect is not reflected in Violence. The body of literature on psychopharmacology and violence is also vast, and a balanced synopsis would be very valuable, especially for residents and those beginning their careers. Unfortunately, Violence does not meet that need. At best, this book is less than helpful, and at worst, it could be misleading.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2015 American Academy of Psychiatry and the Law
